Lithuania

-training in Lithuania is 6 years and they graduate with a masters degree with ability to practice in EMS, ED and palliative care

-EMS services only carried out by EMS personnel, not fire or police

-Ambulance types: BLS, ALS, ALS intensive care

-BLS-minor traumas, cardiac arrest if nearest, transport, psychiatric emergencies, minor medical- Can start IV and apply supraglottic airway, no meds

-ALS- Nurse and driver-paramedic- can administer medications, can interpret EKG, supraglottic devices, intubation, procedural sedation, etc.

-ALS ICU- Doctor, nurse, driver-paramedic- US, terminating CPR, invasive and non-invasive ventilation- most critically sick patients

Riot Dispersal Agents and GSW Management

-Tear gas fall under chemical weapons- designed to be an irritant that leaves no lasting damage (not always the case)

-14 cases of death from these agents, but all have been from people getting struck with the cannister (in the US)

-In Israel have had cases of people dying from chemical itself when deployed in poorly ventilated areas

-No long term studies- there are concerns for long term toxicity

-Decontamination- removing from exposure

-Copious water irrigation

-Velocity of the GSW is what determines damage- high velocity causes worse disruption

-Two types of wounds: 1. Penetrating- enters but does not leave body 2. Perforating- enters and leaves body

-ABI for concern vascular injury- <.9 needs angiography, >.9 but less than 1.0 needs obs

-71% of those with arterial injury have concomitant nerve injury

EDH

-Introduction to Dr. Syed Shah

AAEM

-Est. 1993 to advocate for EM as a specialty

-Key Issues: Advocacy, Board Certification, Corporate practice of medicine, EMTALA, Due process

-AAEM has multiple resources and benefits to include scientific conferences, podcasts, help in establishing/finding democratic groups, etc

-When thinking about your finances, replace your “buts” with “ands”- for instance “I’m about to make 300k a year AND I don’t know what to do with it”, rather than saying “…but I don’t know what to do with it”

-Think about other streams of revenue. Examples: selling a product, content creation, renting room/property

-Take inventory of your life. What does your millionaire life look like? What kind of car do you want? House? What do you want to do with your time?

-Estimate the monthly costs of these. It is likely easier for you to “live your millionaire life” than you might think, and setting these goals and visualizing them can help you in determining your pathway to them.

Ortho tips and tricks for closed reductions

-Purpose- to restore length, alignment, rotation

-Helps with patient comfort, protecting cartilage, keep neurovascular structures away from stress, prevent skin/wound complications

-Also trial of non-operative management

-Needs pre-reduction XR

-Recreate the deformity to “unhinge”

-Consider your deforming forces- what structures at risk, what muscles/forces pulling fracture, what will open joint space, etc.

-Tourniquets can get in the way, so try and take down if possible

-Molding- holds your reduction in place, 3 point mold (never mold over bony prominence)

-Purpose of CT is to evaluate joint

-Rare to obtain CT prior to reduction unless there is a block of some kind

-Every time a joint gets dislocated it will need to stressed to assess for stability- this will determine need for operative management

-Unstable hip dislocations need traction pins

-Elbow test flex/extension + varus and valgus stress

-Unstable dislocations get ex-fix EVEN IF NO FRACTURE

-Joint dislocation is emergent in the ortho world

-Shoulder reduction

              -Do not try alone if there is an associated fracture, TSA or rTSA in place

              -Milch maneuver

              -Stability exam

              -Scapular Y XR and axillary views

-Elbow Reduction- typically associated with ligamentous damage

              -Simple- no fracture, complex- fracture

              -Terrible triad injury- LUCL, radial head, coronoid

              -Inline traction, supination, flexion

              -Stress the joint

              -Neurovascular exam

              -Monteggia- Proximal 1/3 ulna + radiocapitellar jt- make sure that radial head is reduced!!

                            -Blocks to reduction- annular ligament, biceps tendon

                           -Stress- especially pronation and supination- need to splint in whichever is more stable

-Hip- posterior wall fracture

              -often associated with acetabular fracture- if it isn’t try not to cause one

              -Captain Morgan reduction, East Baltimore Lift

              -Flexion, adduction, internal rotation (for posterior dislocation)- Stress exam

              -Make sure to get pre-reduction XR

              -When to ask for help- traction pin, peri-prosthetic

-Knee dislocation- often associated with neurovascular injury

              -First steps- physical exam, doppler, ABI’s?, CTA’s? (not super sensitive for intimal flaps)- typically keep these for obs for 24 hours

              -Vascular consult?

-Subtalar Dislocation

              -Difficult reduction- try and call ortho for this

              -Different than the tibiotalar dislocation (standard ankle dislocation

              -Dislocation of the talus and calcaneus

              -need to relax gastrocnemius muscle- flex the knee

              -Plantar flex the ankle

              -Is the talonavicular joint in place after reduction? Can see on post reduction lateral films

-Remember 3- point mold, and do not mold over bony prominence

-When does it not matter

              -certain fractures- humerus, femur shaft/ distal femur, both bone forearm, tibia +/- fibula

              -Just need to get to length

Lightning Lectures

Dr. Kushner- Kids with a limp

-fractures, muscle/tendon/ligament injury, insect bite, hemarthrosis, transient synovitis, cellulitis/abscess, plantar wart

-SCFE- type I Salter harris fracture

              -most common hip pathology in adolescents

              -Usually happens during periods of rapid growth

              -Risk factors: obesity, family history, endocrine/metabolic disorder, down syndrome

              -Stable- able to bear weight with crutches

              -Unstable- not able to bear any weight

              -Work-up: XR (AP and frog leg), MRI, possible workup for kidney disease or endocrine disorder

              -Non-weight bearing, consult to ortho

              -Unstable needs to be admitted

              -Complications: osteonecrosis, chondrolysis, femoroacetabular impingement

-Legg Calves Perthe- Osteonecrosis of femoral head- idiopathic

              -10-15% will be bilateral

              -Ages 2-12 with peak 4-9

              -Pain in hip, groin, thigh, knee

              -may wax and wane over weeks to months

              -Goals: pain relief, protect femoral head shape, restore hip mvmnt

              -Non-weight bearing, NSAIDS and consult to ortho

-Septic Arthritis- most commonly hematogenous spread

              -most common in hip, knee, ankle

              -Staph aureus, respiratory pathogens, kingella, e coli, salmonella

              -Need to rule out adjacent joint involvement

              -FABER position- Flexion, Abduction, External rotation

              -Workup: CBC, CRP/ESR, blood cultures- possible swabs if suspect gonorrhea

              -XR AP and frog leg

              ->50k WBC and >75% polymorphonuclear cells in synovial fluid suggestive of SA

              -Kochers criteria- fever, non-weight bearing, ESR >40, WBC >12k

              -Consider LP if septic joint caused by H. flu- high incidence of meningitis

              -Try and hold on abx until aspirate and cultures can be obtained

-Transient Synovitis

              -Etiology unclear but typically proceeded by URI, trauma, bacterial infection

              -Treatment NSAIDS, heating pads

              -Should resolve in 1 to 2 weeks- close follow up for resolution

Dr. Aiello- Conus medullaris and Cauda Equina Syndromes

-Conus medullaris syndrome- CM injury typically at L1-L2

              -Findings: Urinary incontinence, fecal incontinence, decreased rectal tone, erectile dysfunction, saddle anesthesia

              -What sets apart from cauda equina- muscle weakness typically bilateral, + upper motor neuron signs, loss of patellar reflexes

-Cauda equina syndrome

              -Begins at L2 and extends to sacral nerve roots

              -Can be asymmetric

              -Usually more painful than conus medullaris

-Management-

              -if neoplasm suspected- dexamethasone 10 mg IV?, MRI w/ contrast

              -Spine consult, likely surgery

R2 Clinical Pathway- Traumatic Injuries of the Spine- Drs. Bishop and Alia

-Up to 25% of SCI occurs after initial insult- extraction, transport, handling, early mobilization

-Spinal tracts:

              -Descending Motor tracts: Lateral corticospinal, ventral corticospinal

              -Ascending sensory tracts: Dorsal columns (fine touch, proprioception, vibration), Lateral spinothalamic (pain, temp), Anterior spinothalamic (course touch, pressure)

-High dose steroids not recommended in spinal cord injury

-Brown-Sequard Syndrome- transverse hemi-section or unilateral compression

              -ipsilateral spastic paresis, loss of proprioception/vibration

              -contralateral pain and temperature loss

-Central Cord syndrome- squeezing of the cord affecting inner portions

              -Quadriparesis worse in upper extremities

              -Cape like distribution

              -Sacral sparing

              -MRI, NES/Spine

-Anterior Cord Syndrome

              -Direct compression or ischemia of anterior 2/3 of spinal cord

                           -disc protrusion, AAA, hyperflexion, emboli

              -Symptoms:

                           -paraplegia below lesion

                           -loss of pain and temp

                           -Bowel/bladder dysfunction

                            -Dysautonomia

-Spinal Shock- injury resulting in transient global loss of function w/ temp flaccid paralysis, bowel/bladder dysfunction, anesthesia, loss of reflexes

              -Resolves in days to weeks

-Neurogenic Shock- injury to spinal column resulting in hypotension, bradycardia, and hypothermia

              -occurs in <20% of SCI patients

              -injury level:

                           -Above T1- full sympathetic denervation

                           -T1-L3: partial denervation

              -Management:

                           -Exclude other causes of vital sign abnormalities

                            -MAP goals- first line pressor (MAP goal 85-90)

                           -Levo first line, can add phenylephrine as second line pressor

                           -Atropine, temp probe, bair hugger

-Unstable fractures:

              -Jefferson Bit Off A Hangman’s Thumb

                           -Jeffersons Burst Fracture- C1 fracture of anterior/posterior arches

                           -Bilateral cervical facet dislocation

                           -Odontoid Fracture, type II (full odontoid fracture) or III (vertebral body involvement)

                           -Atlanto-occipital dissociation

                           -Hangmans fracture- bilateral C2 pedicle fractures- displaces C2 anteriorly onto C3

                           -(Flexion) Tear drop fracture- associated with anterior cervical cord syndrome

-Remember Canadian C-spine, NEXUS criteria for clearing C-spine

-R2 Pathway on room9er

Dr. Jacobs- Life after Residency

-Show up 15 minutes (at least) early for your shifts

-Get to know the people you work with and be friendly

-Avoid arguments

-Flow is important- order everything you think you might need (within reason) right out of the gate- will speed things up ultimately

-Ask for help if you need to- case management, colleagues, PT/OT, nurse manager, etc.

-Don’t vent your anger in public- beware of being recorded

-Temper patient expectations- don’t over-promise, do what you can do

-Don’t get locked into a diagnosis and refuse to budge- avoid confirmation bias

-Listen to your nurses, involve them in care- will help with building relationships

-Recognize your feelings- if you need a minute to decompress or vent, do so before your feelings boil over

-Get a lawyer/accountant/financial advisor onboard early in your career so you can maximize your pre-tax deductions, retirement accounts, etc.

Ortho ppx

-Open fracture classification Gustilo- Anderson

-Size lac, degree soft tissue injury, contamination, vasc comp

-I: lac < 1cm, clean

-II: lac >1cm w/o extensive soft tissue

-III: lac >10 cm w extensive soft tissue injury or amp

-III A, B C

-Open fractures w/ increased incidence of infx/ osteo, vasc injury, nerve injury, compartment syndrome, VTE

-Orthopedic Trauma Association Open Fracture Classification- emerging classification system due to poor interobserver classification- Skin, muscle, contamination, bone loss- score greater than 5 add gram neg

-Goal for abx ASAP, 1-3 hours post injury by EAST guidelines

-Type I and II, Gram + only- Cefazolin 2 g Q8H

-Pts > 120kg get 3 g

-Alt clindamycin 900 mg IV Q8H

-Duration 24 hrs after closure

-Type III Gram + and –

-Cefazolin + Gentamicin or tobramycin 5mg/kg 1 time dose

-Adverse effects of aminoglycosides- Nephrotoxic- make sure adequately hydrated- Ototoxic(irreversible)

-Soil/feces contamination- Clostridium species- 4-6 million units penicillin IV q 4-6h- alt metronidazole 500 mg q 8H

-Fresh water contamination- Aeromonas- Zosyn or cefepime

-If unable can use cipro or levofloxacin

-Salt water Vibrio- Zosyn/cefepime + doxycycline (alt is cipro/levo + doxycycline)

-GSW open fx- EAST guidelines recommend to consider type 3

-Reality- low velocity (handguns) similar management to closed

-High velocity- Rifles/shotguns- similar to type III

-Recs- treat like type I or II unless contamination present. If extensive tissue damage treat like type III

Peds: Ortho/ NAT

-Le fort fractures never occur in children less than 2 due to lack of pneumatization of the sinuses

-Children less than 8- susceptible to ligamentous and growth plate C spine fx that are higher up

-Older children lower C spine fractures more common

-Posterior displaced medial clavicle fx needs CT to ensure no compression of mediastinal vessels or trachea

-Salter Harris classification

-Gartland Classification supracondylar fx- type II and III likely to require surgery

-Galeazzi

-Monteggia-

-Toddler’s Fractures- 12-94 months, low energy trauma w/ rotational force

-Subtalar joints have poor blood supply making it prone to osteonecrosis

-Chopart- separates midfoot from hindfoot- important for pronation and supination

-NAT- TEN 4 FACES P

-torso including genitals, ears, neck, frenulum, angle of the mandible, cheek, eyelid, subconjunctival hemorrhage, patterned bruising

-4- any bruising in a child less than 4 months of age

-95.6% sensitive, 87.1% specific for NAT

-Point tenderness over an unfused epiphysis concern for non-displaced salter harris- need splinting and follow up

-Nursemaids elbow- mechanism is being pulled

-Reduced by hyper-pronation or supination/flexion

-pain is usually at wrist

Tactical Medicine

-Swat developed after the Texas tower incident Aug 1, 1966

-1989 to 1990 interest began in involving medical professionals with SWAT

-Officers to learn methods of self rescue and to provide basic medical care

-TCCC- Tactical Combat Casualty Care

-Hot zone- immediate area with perpetrator- shooting back, moving casualty out of hot zone are priority

-Warm zone- potential for hostile threat, not under direct fire- Immediate care can be performed here- tourniquet, Chest seal/decompress, airway

-Cold zone- No significant threat of danger- more definitive care

-They use (S)MARCH- security, massive hemorrhage, airway, circulation, hypothermia

Nailbed Injuries and Arthrocentesis

-Indication for trephination- less than 1-2 days old, 50% or more of nail bed

-Be careful with flammable alcohols and check for acrylic nails as these are also flammable

-Nail bed laceration- digital nerve block, remove nail, repair w/ 5-0 or 6-0 absorbable sutures, replace nail into fold

-Arthrocentesis- suspicion of septic arthritis, crytal arthropathies, unexplained arthritis W/ effusion, eval of jt capsule integrity in trauma, therapeutic relief of pain/ effusion

-Contraindications: No absolute but relative include overlying cellulitis, prosthetics

– >50k WBC, >90% PMN cells indicative of septic joint

Venous thromboembolism

• 90 day overall PE mortality rates were 17% in 1999, 16% in 2018
• Inari FLASH registry 30 day mortality rates for High and intermediate risk PE patients were 0.8%
• Nearly half of submassive 30 day mortality occurs outside of hospital
• Lightning Lectures:

Pelvic Fractures

-3 month mortality 3x higher in trauma patients with pelvic fractures

-Increased concern for bladder/urethra injury

-Sacral fractures -zone 1, 2, 3- 3 is worst prognostically

-APC 1 <2.5 cm pubic symph

-APC 2 >2.5 + anterior ligament

-APC 3 >2.5 + ant+ post

-Vertical sheer

-Pelvic binders: unstable and pelvic injury suspected. Over trochanters.

-Inlet/outlet films, judet AP and lateral decubitus position once stable

-FAST can help determine if needs lap (+ blood) or embolization

Compartment Syndrome

-1-10% of tibial fractures, ant compartment most common

-Normal compartment pressure < 10 mmHg

-<20 mmHg unlikely to cause damage

-CK, UA for myoglobin (rhabdo in 40%)

-Stryker- compartment >30 mmHg in one compartment

– Delta pressure: diastolic – pressure (30 or less is indication for fasciotomy)

-Fasciotomy w/in 6 hrs 100% recovery

-12 hr 66%

Ortho Plain Films

-Most often missed finding is the 2^nd finding

-More views are better

-Axillary view very helpful in glenohumeral joint evaluation

-Posterior shoulder dislocations- hard to see, patient can’t externally rotate (lightbulb sign), lack of crescent sign

-4 views at the elbow

-Monteggia fracture- Proximal ulnar fracture with dislocation of radiocapetallar joint (radial head dislocation)

-Galeazzi fracture- Mid to distal third of ulna with dislocation of distal radioulnar joint

-Maisonneuve- total disruption of interosseous membrane

Strangulation injuries are a tough chief complaint. We have many considerations in evaluating and managing these patients. Top priority is ABCs, and then ruling out other serious injuries in the patient.

We may tend to have too low a threshold for CTA in these patients. But they often end up in court proceedings and one could argue for the more aggressive imaging strategy for this reason. Of note, strangulation in the setting of domestic violence represents a VERY high risk mechanism to predict subsequent fatal injury in intimate partner violence.

I am not offering a clear cut answer on when to CTA and when not to. This should be a decision you make with the patient and your attending, considering patient age, injury severity, etc. But the two resources below can at least provide some context on evidence for imaging.

1. Check out this algorithm, authored by Dr. Bill Smock who was UL EM faculty for years and worked with the LMPD as the police surgeon for years. He writes the forensic medicine chapters in a few textbooks as well.

Imaging Recommendations for the Medical/Radiographic Evaluation of Acute Adult, Non-Fatal Strangulation

2. Also check out the paper below, authored by UL Emergency Radiology physicians including Dr. Jonathan Joshi.

https://pubmed.ncbi.nlm.nih.gov/31055673/

Pharm review with Jade 

DILI- can be from ABX, antiepileptics, Tylenol

FDA recommendation for Tylenol reduced to 3g for OTC safety however 4g daily is still safe to give 

Max tpa for stroke is 90 mg, otherwise .9 mg/kg. 10% over 1 min, remainder over 1 hour 

BP goal for tpa administration in stroke is 185/110

Criteria is same for alteplase and Tenecteplase 

Bactrim can cause hyperkalemia as an adverse effect 

Keppra load in status 40-60 mg/kg with a max of 4.5 g

Etomidate may lower seizure threshold- not ideal for status patients 

Rocuronium duration of action prolonged in renal and hepatic impairment, advanced age 

GI Review with Dr. Ross

IV glucagon first line for esophageal food bolus however low success rates

Second to adhesions, adenocarcinoma is most common cause of bowel obstruction 

Proctitis- sexually transmitted, treat with same empiric STI abx

Traveler’s diarrhea- give azithromycin if pregnant otherwise cipro is fine 

IBS- FODMAPS diet 

Esophageal candidiasis: if immunocompromised give systemic antifungal, otherwise topical 

Pyloric stenosis: hypochloremic hypokalemic metabolic alkalosis 

Pancreatic cancer- troussaeau syndrome aka thrombophlebitis 

HBsAg- active infection, anti- HBs is recovered or immunized

Sigmoid volvulus- flexible sigmoidoscopy 

Wilderness Review with Dr. McGowan 

Lightning strike triage is different- go to the coding pts 

Pulseless leg after lightening stroke- kerunoparalysis 

EKG finding in hypothermia- J wave/Osborn wave 

Mild hypothermia 90- 95. Shivering uncontrollably. Moderate hypothermia stop shivering 

Severe hypothermia- risk of dysrhythmia with movement 

Normal ACLS not beneficial with temp below 88-90. Reasonable to attempt 1 defib and 1 epi

K>12 is reason to cease efforts 

Rewarm frost bite with hot water immersion, do not warm if potential for refreezing 

AMS differentiates b/t heat exhaustion and heat stroke 

Air gas embolism occurs on surfacing-> hyperbarics

Nifedipine can be used to treat HAPE if unable to descend 

Immediate descent for HACE

OBGYN Review with Dr. Platt 

AUB= consider cancer in women over 45 yo F

US imaging of choice for genital tract pathology 

Ovarian cyst > 8cm, solid, multiloculate are worrisome for neoplasm, dermoid cysts, or endometriomas

An ovary > 4 cm in size is the most common US finding associated with torsion 

False labor= uterine contractions that don’t cause cervical changes 

Amniotic fluid changes nitrazine paper dark blue 

Sterile speculum exam, no digital exam if ROM suspected 

If vaginal bleeding during second half of pregnancy, perform US prior to speculum or digital exam

DED/72 Hr Return Learning highlights with Dr. Royalty

A patient is considered refractory after 3 or more defibrillators, 3 or more doses of epinephrine, AND 300 mg Amiodarone 

What therapies can you try?

-Hold additional epinephrine 

-Administer Esmolol for electrical storm: 500 mcg/kg bolus followed by infusion (50-100 mcg/kg/min)

-Dual-sequential Defibrillation: Place a second set of pads (R upper chest/left lateral and anterior/posterior), deliver 200J simultaneously from both defibrillators

Pediatric Cardiac Disease with Dr.Wadih

Cyanotic lesions: 5 T’s-Tetralogy of Fallot, Transposition, Tricuspid atresia, Truncus arteriosus, TAPVR

Truncus arteriosus: Associated with 22q11 deletion (DiGeorge), Primitive truncus does not divide into PA and aorta, Leads to significant pulmonary over circulation, Ductal independent 

Tetrology of Fallot: Large VSD, RVOT obstruction, RVH, overriding aorta. Tet spells= episodes of cyanosis usually triggered by crying. Treat tet spells by calming, knees to chest, supplemental O2, morphine, IN fentanyl or versed if no IV, IVF to increase preload. If these fail, move to beta blocker propranolol or esmolol, ECMO last resort. Degree of RVOT obstruction determines if lesion is ductal dependent. All require surgery

Total anomalous pulm venous return: Pulm vein do not return to L atrium, degree of illness depends on degree of obstruction of pulm venous return. Ductal independent. Must have ASD to survive 

Transposition of Great arteries: Must have large ASD , VSD, or PDA to survive. Usually presents within hours of birth. If not responding to prostin need a balloon atrial septostomy.

Tricuspid atresia: Absence of tricuspid valve w/ hypolastic RV. Relies on ASD 

L->R shunts: ASD, VSD, PDA, AV canal 

ASD: rarely symptomatic, usually close on their own. Typically close ASD around age 2-5 if becomes larger or persists. “fixed split S2” is a buzzword for ASD on exam 

AV canal (AV septal defect) commonly associated with trisomy 21. Spectrum of severity, all require repair 

VSD: Highly variable. Bigger VSD= more likely to cause heart failure, less likely to hear on exam. Smaller VSD= less likely to cause issues and may close on their own, louder murmur on exam. Over time will lead to increased PVR, increased RV pressure and RVH. May present at 4-8 weeks of life in heart failure, slightly later in trisomy 21

PDA: Machine like murmur at left upper sternal border. Persistence of ductus arteriosus. Ibuprofen used to encourage closure. More common in premature infants 

Ductal dependent lesions (depend on PDA): HLHS, critical aortic stenosis, critical coarctation of aorta, pulm atresia, +/- tet

These NEED PGEs. Prostaglandins cause apnea. Presents with murmur, cyanosis, heart failure on exam. Poor feeding with poor weight gain, sweating with feeds, irritability, tachypnea. W/u with pulse ox: R hand is pre ductal, >3% difference b/t pre and post ductal sats. Need CXR, EKG, Echo. Give prostaglandin .05-.1 mcg/kg/min, watch for apnea. Milrinone typically inotrope of choice due to vasodilation (doesn’t increase SVR). Consider epi for shock 

Coarctation of aorta: As PDA closes- hypoperfused lower extremities, hypertensive upper extremities, associated with turner’s. Present in shock as PDA closes. Coarct located pre-ductal is ductal dependent. Coarct other locations may not present until later in life 

HLHS:Hypoplasia of LV and ascending aorta, mitral valves with ASD and PDA. Cardiogenic shock when PDA closes. Mortality highest in 1^st year of life. Staged repair, first stage is Norwood(BT shunt connects PA and aorta) which is done during the 1^st few weeks of life. IF BT shunt clots they will die. 12% rate of clotting. Post op period is high risk. Listen for a shunt murmur

If you think shunt closed, bolus heparin and start drip. Consider ECMO, likely needs emergent surgery. Increase SVR with pressors (epi first choice), sedate and paralyze to reduce PVR( intubate). Once make it through staged repair survival rate is 90% at 30 years old. Atrial arrythmia is common comorbidity, also liver failure 

Ebstein’s anomaly- associated with maternal lithium use. R atrium enlargement, malformed tricuspid valve 

Eisenmenger syndrome: complications of uncorrected L->R shunt. Can occur in childhood or adulthood depending on the lesion. Cyanosis, syncope, dyspnea, fatigue, chest pain, sudden death. Increased pulm resistance, pulm HTN causes shunt to switch to R->L

Thoracic review with Dr. Baker 

Light’s criteria- if any one of the following is present the fluid is almost always an exudate: pleural fluid/serum protein ratio > 0.5, pleural fluid/serum LDH ratio > 0.6, pleural fluid LDH > 2/3 upper limit for serum LDH 

TB drug side effects: Ethambutol can cause optic neuritis.. starts with E and is eye pathology. Rifampin= orange body fluids. Isoniazid= peripheral neuropathy, seizures, B6

-Spontaneous PTX >20% needs chest tube. Smaller can be observed with oxygen administration 

-To prevent BPD in neonates: within one hour of birth give neonate surfactant, after an hour give caffeine. Risk factors are tobacco use, IUGR, preeclampsia

-Tracheoinonomate artery fistula. Overinflate cuff-> intubate-> remove trach-> digital compression of innominate artery 

-Pertussis buzz words: several weeks, eye sxs, post-tussive emesis 

-Coin position on xray: SAFE= sideways airway, frontal esophagus 

Most common symptom in PE: dyspnea

Most common sign in PE: tachypnea 

Tolerating secretions and toxic= tracheitis

Drooling and toxic= epiglottitis (Hib), thumbprint sign 

Spontaneous and stable Pneumomediastinum: dc with f/u. asthma most common trigger.. Hamman sign, pleuritic pain and neck pain. Usually self-resolving 

-Gram+ cocci in clusters= staph aureus 

-PNA+ bullous myringitis= Strep pneumo Phosgene smells like hay or cut grass 

CURB65: confusion, BUN>19, RR > 30, SBP <90 or DBP < 60, Age > 65

Berylliosis= Aerospace, fluorescent bulbs

Silicosis: glass, sand blasting, miners

Asbestosis: shipyard workers

Siderosis: arc welding (iron)

Most specific US finding for PTX: lung point sign 

Pneumocystis jirovecci: elevated LDH

Give prednisone if PaO2 less than 70 

Fat embolism: IVF and supplemental O2, may see petechial rash

Case Reviews with Dr. Weeman and Dr. McMurray

Meningitis

• Strep Pneumo most common pathogen, consider when recent sinusitis or OM
• N meningitis: group living, recent exposure, rash 
• S aureus: IVDU
• HIV/immunocompromised: also consider Listeria, cryptococcus, TB
• Perform CT prior to LP if any focal deficit, seizure, AMS,  hx tumor, age > 60, papilledema 
• Give steroids (10 mg IV dexamethasone) 20 min prior to Abx as part of your empiric coverage because it decreases mortality in S pneumo 

TTP 

TTP is decreased ADAMTS-13 which cleaves vWF, without it vWF forms multimers that lead to microthrombi 

Present with fever anemia thrombocytopenia, renal failure, AMS, only 20-30% of pts have the classic pentad 

Microthrombi result in end organ damage 

Dx with plt <20K, MAHA, schistocytes, elevated retic count, LDH, unconjugated bilirubin

Normal coags and normal fibrinogen

Tx: steroids, FFP, HD can temporize 

Gold standard is PLEX which removes autoantibodies and replaces ADAMTS-13

Avoid platelet transfusion-> provokes thrombosis

Caplacizumab is a monoclonal antibody against vWF to impede interaction with platelets, very expensive.. not prescribed if plts >30K. Prescribed for prevention but may also be used in inpatient management 

Tox Review with Dr. Eisenstat

-Contraindications to activated charcoal include aspiration risk (think of toxins with high risk of seizures, somnolence, vomiting, etc)

-GHB acts on GABA receptors. Short acting. Classic case is obtunded requiring intubation then later self extubates

-Organophosphate toxicity: Tx with atropine and pralidoxime 

-Serotonin syndrome: clonus, give cyproheptadine 

-NMS give bromocriptine, malignant hyperthermia give dantrolene

-Cyanide toxicity: house fire with lactic acidosis, hypotension, bradycardia. Gives hydroxycobalamin 

-Amatoxin containing mushroom-> NAC

-Digoxin toxicity-> Don’t give calcium. 

-Indications for hyperbaric for carbon monoxide: Carboxyhemoglobin level >25% or >15 if pregnant, also anyone with LOC or severe lactic acidosis 

ID Review with Dr. Shoff

-Flexor tensynovitis-> Kanavel’s signs: pain with passive extension, percussion tenderness, uniform swelling, flexion posture

-Most common septic arthritic: Staph aureus 

-Missisppi Valley-> histoplasmosis

-Southest US-> blastomycoisis 

-California-> coccidiomycosis 

Varicella: lesions in various stages

Smallpox: lesions in same stage 

Pertussis: treat close contacts

Rabies: PEP for any bat exposure. Vaccine day 0,3,7,14. Administer immune globulin around wound, any leftover goes IM

Lightning Lecture – Advance Directives
– Living Wills – May contain DNR but typically do not
– Health Care Proxy – legal document that establishes who makes decision on behalf of the patients
– DNR orders can vary by state
– There are different types of DNRs
– POLST/MOLST – Physician/Medical Orders for Life-Sustaining Treatments – Kentucky’s newest forms
– Be open, honest, and compassionate when it comes to discussing end-of-life care
– At ULH, we have 24/7 palliative care services which are available in the ED

Lightning Lecture – Steven-Johnson Syndrome
– Extreme immune reaction causing keratinocyte necrosis diffusely
– Causes – medications, infections (Mycoplasma pneumonia), malignancy, immunosupression (HIV)
– Onset 1-3 weeks
– Prodromal viral symptoms – headache, fevers, msk pain
– Macular rash with bull -> skin sloughing (+/- Nikosky sign)
– Genital lesions, GI necrosis, pneumonia, interstitial pneumonitis
– Workup – basic labs, inflammatory markers, CXR
– ScorTEN – scoring algorithm to assess overall mortality
– SJS <10% TBSA involvement
– SJS/TEN Between 10-30% TBSA involvement
– TEN > 30% TBSA involvement
– Treat it like a burn – stop suspected offending agent, give a significant amount of IVF, local wound care, pain management

Interesting/Important EKG Findings
– P waves best seen in V1 and lead II
– In lead II, SA node P waves should be upright
– In lead VI, SA node P waves should be biphasic
– P pulmonale – right atrial enlargement
– P mitrale – left atrial enlargement
– Q waves usually occurs in the setting of post-MI
– Not all Q waves are indicative of MI
– One small box wide and one small box deep inside the Q wave is more indicative of pathologic Q waves
– T Waves – predominately upright
– Usually when inverted they represent ischemia vs strain
– U waves are rare upright waves following T waves typically only seen in significant dysfunction and illness
– Normal QRS: 60-100msec
– Incomplete BBB: 100-120msec
– Complete BBB: >120msec
– Short QT (500) Syndromes exist
– R wave progression – R waves should slowly appear through the precordial leads
– Should at lest be present by lead V2
– R should be isoelectric around V2-V3
– R wave should peak by V4-V5
– Early RWP can be lead placement, RVH, PHTN, or RBBB
– Late RWP can be old infarct, lead placement, LBBB
– Bundle Branch Blocks
– Is the terminal QRS deflection (last deflection) positive in V1? then in is a RBBB
– Is the terminal QRS deflection (last deflection) negative in V6? then in is a RBBB
– Is the terminal QRS deflection (last deflection) negative in V1? then in is a LBBB
– Is the terminal QRS deflection (last deflection) positive in V6? then in is a LBBB
– Most of the time, a true new LBBB does not pass the “eye test” – i.e. they look terrible in person
– If higher STEMI in Lead II vs Lead III -> likely LCx lesion instead of RCA lesion
– aVR – care about it because it can represent a left main lesion
– Reciprocal changes help identify a posterior MI
– Sgarbossa Criteria
– Concordant ST elevation > 1mm in leads with a positive QRS complex (positive terminal deflection of QRS complex with elevation in the T wave)
– Concordant ST depression > 1mm in V1-V3 (negative terminal deflection of QRS complex with depression in the T wave)
– When to obtain a posterior EKG:
– If posterior heart is infracting, should have reciprocal changes in the anterior waves (V1-V3)
– Lead II, Lead III, Lead aVF all negative deflections – this makes it a LAFB – NOT a LBBB equivalent
– A flutter – rate around 300bpm, vent rate usually 2:1
– AVNRT is the most common form of SVT
– Brugada Algorithm exists
– 200j is a good idea for most everything
– Run a 12 lead rhythm strip if possible while defibrillating unstable arrhythmia
– Causes of cardiogenic syncope
– ARVC, QT Syndromes, Conduction Delays, Etc
– Short PR interval in the right setting is a sign of WPW
– Brugada has types?
– Brugada pattern is when EKG changes present without symptoms
– Brugada Syndrome – EKG changes with syncope, chest pain, heart failure symptoms
– Metoprolol has more significant breakthrough events with long QT syndrome so Propranolol and/or Nadolol are preferred
– T wave inversions present in V1-V3 with syncope is concerning ARVD – look for epsilon waves – notching immediately after QRS
– Arrhythmogenic Right Ventricular Dysplasia
– Fatty infiltrative disease of the right ventricular free wall

Brief Review of Statistics
– Normal Distribution – 68%, 95%, 99.7%
– P value is the probability that the observed effect within the study would have occurred by chance if, in reality, there was no true effect
– Confidence interval provides a range of values within a given confidence including the accurate value of the statistical constraint within a targeted population
– Type I Error – the result of the study is said to be statistically significant but in-reality it was not
– Type II Error – the result o the study is said to not be statistically significant but in-reality is was
– Closely associated with the power of the study
– Power – ability to correctly reject a null hypothesis that is indeed false
– Higher powered studies are better when evaluating high risk and/or life-threatening stuff?
– SPin and SNout
– PPV and NPV
– Higher prevalence, higher PPV and Lower NPV
– memorize the chart
– Prevalence – total existing cases/total population
– Incidence – new (over a certain time period) cases / total population
– Precision vs Accuracy
– Probability – event of interest / total events measured
– Odds – event of interest / not event of interest
– Risk Ratio – probability of one group / probability of another group
– Odds Ratio – odds/odds
Confidence intervals -> crosses 1 -> no difference
– Meta-analyses and Systemic Reviews are the best type of evidence based medicine
– High bias = low validity

IVC POCUS Lecture
– POCUS is just one data point
– How to perform an IVC View
– Start with the traditional subxiphoid view and rotate the probe 90 degrees (indicate to the head if abdominal probe, indicator to the toes if cardiac probe)
– How to measure the IVC
– Don’t use M Mode – the least right way to perform this study
– Use B Mode
– Measure 2cm from IVC/RA junction or 1cm from IVC/hepatic vein junction
– Freeze the image, use cine mode to find the maximum and minimum of the images
– Caval Index – (max – min)/max x 100
– Note, if the patient is vented, the change collapse is reduced
– If IVC appears small/collapsible or plethoric, that is when this US is very useful
– Different commonly used terms for these findings:
– Volume Status – poorly defined term
– Volume Responsiveness – better defined term
– Volume Tolerance – “Can the RV handle it? Can the LV use it?
– Note – CVP does not equal volume responsiveness

“What in the Baby is Going on Here”
– Thrush – can present on most surfaces in the oropharynx – treat with oral nystatin and need to sterilize all bottles/nipples
– Periodic Breathing – differentiate from apnea – concerning characteristics – pauses 20+ seconds, cyanosis, increased web – normal, resolves around 6 months of age
– Jaundice – breast fed vs formula fed? stool transitioned? birth weight? term vs preterm? any siblings needing phototherapy? ABO compatibility and/or other risk factors?
– Unconjugated Hyperbili – increased bilirubin production (hemolysis) vs decreased bilirubin clearance vs increased bilirubin circulation (breast mild jaundice) vs breast feeding jaundice (inadequate intake)
– Labs: total and diet bilirubin, CBC with Diff, reticent count, CMP, Coombs/DAT
– Start phototherapy and/or double up phototherapy
– Normal Saline bolus ( +encourage feeding if otherwise stable)
– Trend total bilirubin as an inpatient
– Neurotoxicity risk factors: GA < 38, albumin <3, isoimmune hemolytic disease, sepsis, concerning symptoms within 24 hours
– Omphalitis – different from umbilical granuloma
– Management: CBCd, Blood Culture
– Treatment: Admit for IV antibiotics: Vanc and Pip/Tazo
– Febrile Neonate
– CBC, CMP, CRP, Procal, Blood Culture, POC Glucose, UA with UCx, HSV Swabs, Lumbar Puncture for CSF Studies
– Treatment: IV Antibiotics and possibly antivirals (Ceftaz, Amp, Acyclovir)
– Hypothermic Neonate
– No clear consensus on management/workup at this time
– 96.5F is the partial consensus, WHO definition is <36.5C (97.7F)
– Bundling/skin-to-skin contact
– If well-appearing, try re-warming, if failed, then start a septic workup
– If ill-appearing, full septic workup and IV antibiotics
– Lethargy
– Ingestion, too, hypoglycemia, seizure, meningitis, sepsis, NAT/Head Trauma, intussusception, inborn error of metabolism, congenital adrenal hyperplasia, cardiac etiology

Opioid Use and ALTO Therapy
– Every week of opioids prescribed corresponds with an additional 20% increased risk of overdose and/or misuse
– Kentucky SOS (Statewide Opioid Stewardship)
– Reduce opioid prescribing by reducing opioid use
– ALTO – Alternatives To Opioid
– 600mg Ibuprofen and 1000mg Acetaminophen does the world good
– Toradol 15mg IV/IM has similar analgesia without additional side effects seen with higher doses
– IV Lidocaine 1.5mg/kg over 15 minutes (max 200mg) – use extremely cautiously due to side effects
– Do not use if pregnant, seizure history, severe cardiac disease, history of arrhythmia
– Ketamine 0.15mg/kg (max 20mg) over at least 5 minutes
– Magnesium 15mg/kg (approximately 1-2grams) over 15 minutes
– New Renal Colic PowerPlan has been created – ED Renal Colic PowerPlan
– Naproxen 500mg BID as a discharge med is probably the best NSAID for patients with complex cardiac histories

Campus Health Counseling 101
– Services are free, confidential, and do NOT impact your student/resident records
– Clinical services, couples counseling, psychiatric services, crisis services, case management and referrals
– Can call 502-852-6446 Campus Health to schedule an appointment – M-F 8-1630
– Currently there are two licensed counsellors but they are hoping to expand to four licensed counsellors shortly

Lightning Lecture – Necrotizing Fasciitis
– Fournier’s Gangrene – polymicrobial, associated with T2DM, if on SGLT2 inhibitor they are at higher risk
– If have any suspicion at all, consult surgery immediately
– Use broad spectrum ABx – vancomycin + Meropenum or Zosyn + Clindamycin
– Additional Therapies: IVF, Tdap booster, pRBCs if needed
– Hyperbarics and/or IVIG is controversial
– Factors that increase mortality – WBC>30000, Creatinine >2, Age >60, TSSS, Clostridial infection, Delay in surgery >24 hours

Lightning Lecture – Skin Cancers
– Basal Cell Carcinoma is the most common type and it is the least aggressive form
– Rarely metastasizes
– White skinned people are the most affected
– More common in older individuals and men
– Biggest risk factor is exposure to UV light, possibly more important in childhood years
– Nodular BCC is the most common type
– If noted in the ED, referred to dermatology
– Cutaneous Squamous Cell Carcinoma
– More malignant
– Affects white individuals more
– Same risk factors
– Cutaneous SCC in situ (Bowen’s Disease) is erythematous, well-demarcated scaly plaque
– Diagnosis based on skin exam and biopsy
– IF seen in the ED, refer to Dermatology
– Melanoma
– 5th most common cancer in men and women in the US
– Survival depends on when it is diagnosed
– ABCDE criteria
– Management – refer to dermatology
– LDH levels can be elevated if metastatic
– Most common site of mets = LN, skin, lung, liver, brain
– Karposi Sarcoma
– AIDS-defining illness
– Vascular tumor associated with HHV8
– Typically develops in those with CD4 counts less than 200
– Corticosteroid use increases the risk for development of KS undergoing organ transplant or those with lymph-proliferative disorders
– If noted in the ED, bigger concern is significant immunocompromised state

Discussion of Burn/Wound Care Dressings
– Adaptic – vaseline impregnated gauze – applied after a topical ointment
– Cuticerin is the same as adaptic but it is typically larger – impregnanted with aqua-phor
– Vaseline Gauze – larger sizes, impregnanted with more vaseline than adaptic
– Mepilex can be used for up to 7 days technically – silicone based dressing – great simple dressing for a smaller burn wound
– SSD is a sulfa drug and is oculo-toxic so it is not recommended for for face and/or hands, bacitracin is typically a safe option

Caustics Lecture
– Caustic = any xenobiotic that causes functional and histologic tissue damage
– Kids are more likely to be damaged with ingestions due to smaller areas of mucosa, so burns are relatively larger to body area
– Ophthalmic Exposure
– Irrigate, irrigate, irrigate
– Morgan lens vs taping a cut IV near the eyelids
– No intervention really reduces injury from a caustic ingestion
– Some evidence that steroids may help reduce GI strictures down the line but evidence is flimsy but may also harm
– Do not neutralize acids with a base due to exothermic reaction
– Prophylatic ABx is not warranted
– When to scope for ingestion – early but not too early
– <12 hours may be too quick for tissue injury to fully demarcate
– >72 hours may be too late because tissue is weakest at this time and iatrogenic injury is more likely
– The presence of oral injury does not correlate/indicate the degree of mucosal involvement further along in the GI tract
– If evidence of perforation – don’t call GI, call cardiothoracic surgery and/or general surgery
– Persistence of symptoms, intentional ingestions should normally be scoped
– If a kid with unintentional ingestion looks good, is tolerating po intake, and is observed for a few hours, can go home
– Hydrofluoric Acid is bad
– Systemically – drops concentration of calcium significantly – time of onset is inversely related to concentration
– Higher concentration is quicker
– Greater than 50% concentration will likely cause immediate injury
– Give calcium and magnesium as quickly as possible
– Place a central line for calcium chloride rather than gluconate
– Keep giving calcium until vtach and/or vfib resolves
– Start calcium and mag immediately
– Can reduce dermal absorption with calcium gluconate gel – if no gel, then can grind up tums in aquaphor and/or bacitracin
– If a hand, fill a glove with this calcium gel

PALS vs ACLS Lecture
– When to pick which one? if over 50 kilos, typically use adult dosing
– PALS – Bradycardia Pathway
– Causes – hypothermia, hypoxia, and/or medications
– Treatment – oxygenation, epinephrine, atropine
– Start CPR is HR is less than 60bpm in neonates/infants
– Young kids are heart rate dependent, cannot compensate as well
– Atropine max dose is reduced in PALS vs ACLS
– Weight Based dosing with adenosine (up to 6mg, 12mg, and/or possibly 18mg)
– Procainimide and/or amiodarone are also options for SVT as well
– PALS – pulseless arrhythmia – epi + shock
– 5mg/kg of Amiodarone for pediatric patients but no clear max per PALS algorithm
– Endotracheal epinephrine (max 2.5mg) due to lower rate of absorption – followed by 3-5 puffs of positive pressure ventilation
– Asystole/PEA pathway is the same
– Give Epi after a pulse check if it is due around time of pulse check for maximum effect
– Rapid Sequence Intubation
– Pre-mediation
– Atropine – children under the age of 1 year of age to prevent bradycardia
– Max dose of 0.5mg in child, 1mg in adolescent
– Dose is 0.02mg/kg
– Lidocaine – controversial and falling out of favor
– Dose is 1mg/kg
– Max dose is 100mg
– Adverse effects are bradycardia and hypotension so may be more harm than good
– Pain/Sedation Medications
– Midazolam – Gaba agonist
– Dose 0.1mg/kg
– Fentanyl – Mu opioid receptor
– Dose 1mcg/kg
– Max dose is 100mcg
– High Dose therapy is 5mcg/kg
– Should be given slowly over 2-5 minutes to prevent chest wall rigidity
– Ketamine
– Dose 0.5-3mg/kg – usually 2mg/kg for intubation
– Possible increase in ICP but more likely increases CCP rather than ICP
– Causes a lot of secretions when given to younger individuals
– No data in those less than 3 months of age
– Etomidate
– stimulates GABA receptors to block neuroexcitation
– Dose 0.2 – 0.6mg/kg – max dose 20mg
– Does cause some adrenal suppresion, so not perfect in those with sepsis
– Propofol
– GABA agonism and decreased glutamatergic activity via NMDA receptor blockade
– Rocuconium
– non-depolarizing blocker
– Dose 1mg/kg
– Half-life of 30-45 minutes
– Succinylcholine
– depolarizing neuromuscular blocker
– Dose 1-2 mg/kg (max 200mg)
– Increased ICP

Cocaine Lecture
– Amphetamines push out more neurotransmitters whereas cocaine blocks re-uptake
– Functions as a norepinephrine re-uptake blocker
– The only local anesthetic agent that is also a vasoconstrictor
– Cocaine can cause a brief transient bradycardia secondary to stimulation of the vagal nuclei followed by a quick tachycardia
– Microwave cocaine + baking powder = crack cocaine which can now be smoked
– Cocaine effects – persistent rhinitis, intra-nasal erosions, epistaxis, crack eye (ulceration from crack smoke)
– Increases body temperature – hyperthermia not a fever – worsened by psychomotor agitation and vasoconstriction at the skin
– Elevated core body temperature is directly linked to mortality
– Can develop seizures from cocaine – sympathomimetic effect and sodium blocking effect (same at TCAs)
– Cocaine increased risk of strokes, myocardial infarction (risk >24x in the hour after ingestion)
– Cocaine affects gestational birth weight, fetal growth, and the likelihood of a term delivery
– Also increases the risks of abruption, spontaneous abortions, and IUGR
– No real decon strategies for people with traditional use
– Decon strategy for a packer/stuffer – whole bowel irrigation to help move the packets along
– Do not use if any evidence of gut wall ischemia is present as this could lead to perforation
– If a packer has evidence of ruptured packet, needs to go to the OR stat
– No role for dantrolene if a patient is hyperthermic from cocaine overdose
– Start cooling around 105, stop around 101

Mycobacterium lightning lecture

• TB
  • 1/3 of world infected with TB
  • 2^nd leading cause of death
  • Symptoms
    • Cough
    • Hemoptysis
    • Night sweats
  • Management
    • Respiratory isolation
    • Contact health department
    • Isoniazid/rifampin/pyrazinamide/ethambutol
• Tuberculous Lymphadentis (scrofula)
  • Enlarging painless neck mass in child
  • Treated similarly as TB
• M. Leprae
  • Dry hypopigmented macules
  • Hair loss
• MAC
  • CD4 < 75
  • Fever/dyspnea/night sweats/cough
  • Azithromycin/erythromycin/ethambutol
• M. Marinum
  • Ascending lymphangitis in aquarium workers
  • Azithromycin or clarithromycin with ethambultol.
  • Treat for 25 weeks.

Rabies lightning lecture

• Acute progressive encephalitis
• Bats are #1 vector in the US.
• Management
  • Treatment is palliative in symptomatic patients
  • Postexposure prophylaxis is recommended if bite cannot be ruled out
    • Watch animal for 10 days if available
    • High risk animals – raccoons, skunks, foxes, bats
    • One dose of HRIG and 4 doses of rabies vaccine over a 14 day period. 5 of 28 days if immunocompromised
• Tetanus
  • Neuro illness from toxin created by clostridium tetani
  • Generalized – diffuse muscle spasms and rigidity
  • Cephalic – cranial nerve palseys
  • Neonatal- passed from unvaccinated mothers

Public Health Updates

• Restaurant inspections, STD tracking, vaccination tracking, septic systems
• Important to find niche outside of EM in your career, Public health could be a good option
• Covid
  • Significantly decreased level of acuity since onset.
  • Downtrending cases and deaths
• Yearly patterns
  • Upticks in November/December and right at start of school year
• Myocarditis
  • Can get from vaccine, but also from covid at an even higher rate

Lightning Lectures

• HIV
  • 1.2 million infected in US, 30-40,000 new cases per year
  • At risk populations
    • MSM 67%
    • Heterosexual contact 24%
    • IV drug use 6%
  • AIDS
    • CD4 count less than 200 or with AIDS defining illness
  • Considerations
    • Privacy when discussing matter with patient
    • Consider AIDS defining illnesses and contraction of rare illnesses
    • Low threshold to start antibiotics if ill appearing
  • History 
    • Does patient know CD4 count or viral load
    • Are they compliant with medications.
  • West Nile
    • Most common in US
  • Dengue
    • Most common worldwide
    • Can cause hem fever
  • Yellow Fever
    • Can cause hem fever
  • Chikungunya
    • Can cause hem fever

Sepsis Clinical Pathways

• Widespread inflammation and organ distress initiated by any type of microorganism
• Leading cause of hospital death 15-20% mortality overall, 50% if associated septic shock
• Defined:
  • Sepsis – suspected infection with SIRS+ or lab abnormalities
  • Septic shock – suspected or proven infection, signs of inflammation, signs of organ failure, + requiring pressors after fluid resuscitation. 
• qSOFA
  • AMS, RR>22, SBP<100
• SIRS
  • Temp < 96.4 or > 100.4
  • HR > 90
  • RR > 20
  • WBC > 12,000 or < 4,000
  • Meeting 2+ criteria is positive SIRS response
• Within 3 hours of patient presentation
  • Lactate measurement
  • Cultures > abx administration
  • 30ml/kg crystalloid fluid
  • repeat lactate before 6 hours
• Resuscitation
  • 20-30ml/kg LR if appropriate for patient
  • broad spectrum abx
  • If BP not responsive, vasopressors (norepinephrine) with target MAP 65 
• Abx
  • Vanc/zosyn or vanc/cefepime
    • Cefepime does not cover anaerobes

Multi-Drug Resistant Organisms: management overview

• MDRO – organism resistant to one or more classes of antibicrobial agents – CDC
  • Organisms of significant concern are resistant to MANY
    • VRE, ESBL, Carbapenemase producing organisms
  • Antibiogram available at pharmacy desk!!!
    • Use this when choosing your antibiotics please
  • VRE treatment
    • Daptomycin or linezolid
      • Both are equivalent 
  • ESBL treatment
    • Cystitis
      • Macrobid, Bactrim, fosfomycin
  • CRO treatment (consult ID)
    • Serine carbapenemase susceptibility
      • Ceftazidime/avibactam
      • Meropenem/vaborbactam
    • I mipenem/relebactam
    • Metallo-betalactamase susceptibility
      • Aztreonam+ceftazidime/avibactam

Documentation Changes

• Will Begin in January 2023
• MDM based
  • Number and complexity of problems addressed
  • Amount or complexity of data reviewed
  • Risk of complications
• Make sure you document all diagnoses considered in your workup.

Pericardiocentesis

• Perform if tamponade present
• Usually from penetrating trauma
• 2 techniques: parasternal and subxiphyoid
• 18guage spinal needle with angiocatheter
  • insert needle, aspirate during insertion until blood return, advance angiocath, draw off fluid until improvement, place stopcock.

Tick Born Disease

• prevention
  • insect repellant
  • Tick removal ASAP
    • Grab as close as possible to skin and pull straight off without twisting
• Lyme
  • B. burgdorefi
  • Ixodes tik
  • Erythema migrans (20% may not have rash)
  • Disseminated disease if untreated
    • Bells palsy – bilateral
    • Migratory arthritis
    • Heart block
• STARI – sourthern tick associated rash illness
  • Rash after being bit by tick
  • Lonestar tick – white dot on back
  • Does not cause severe disseminated disease
• RMSF
  • Macular/popular rash > Petechial Rash on extremities
  • Rickettsia rickettsi
  • Carried by Dog tick
  • Clinical diagnosis
• Erlichiosis
  • Carried by lonestar tick
• Anaplamosis
  • Ixodes tick
• Tick borne relapsing fever
  • Borrelia species
  • Soft shell tick
• Treat with docyycline for all

• Babesiosis (martha’s malaria)
  • Babesia microti
  • Peripheral smear with parasites (maltese cross)
  • Atovoqone and arythromycin
• Tularemia
  • Francisella tularensis
  • Lonestar tick and dog tick
  • Also in flies/contaminated meat
  • Conjuncitivis/ulcerative lesions, tonsillar exudate, typhoidal form
  • Treat if any antibody is +
    • Streptomycin 1g IM BID
• Tick Bite prophylaxis
  • Confirmed ixodes tick
  • Engorged or present graeter than 36 hours
  • Has it been 72 hours since removal
  • Can they take doxycycline
  • Is it a lyme endemic area? Ky is not.
  • IF all answers are yes – 1 dose of 200mg doxycycline

Check out this new essay in Annals EM. Well written. Our job is pretty amazing.

The Eye of the Storm – Annals of Emergency Medicine

Wernicke Encephalopathy

• Encephalopathy, ophthalmoplegia, ataxia only present in 15% of cases
• Clinical Diagnosis
• Treatment
  • Start empiric thiamine, give with glucose
    • Prehospital though, give glucose first since thiamine not available for EMS
  • 500mg IV Thiamine TID for 2-3 days
• Ocular changes improve in 1 day
• Ataxia and confusion may take a week to improve

HHS

• Typically T2DM
• Mortality 10-20%
• Complications- cerebral edema
• Evaluation
  • Glucose (Typically >600)
  • Osmolarity >320
  • Bicarb relatively normal
  • pH relatively normal
  • Ketones (Low or negative)
• Treatment 
  • Fluids typically 8-12 L deficit
  • ICU admission